U1L5: Physical Assessment

components of health supervision (7)

- hx & physical assessment

- development & behavioral screening

- sensory screening

- risk based screening

- immunization

- anticipatory guidance

- parent child interaction

what does AAP recommend for the frequency of health supervision encounters?

32 visits through age 21 yrs for ppl w/o heath problems

timeline of recommended health supervision visits

- newborn

- 1 week after birth

- months 1, 2, 4, 6, 9, 12, 15, 18, 24, 30, 36

- then yearly

how can you minimize anxiety during physical assessments w children? (5)

- start w least invasive to most invasive

- allow child to maintain eye contact w parent

- encourage caregiver participation

- maintain privacy

- allow child to touch equipment

why is typically a comfortable position for a child while undergoing a physical assessment?

sitting -> lying down can be vulnerable for children

general guidelines for effective communication (4)

- introduce self & role

- acknowledge child first

- talk to child at eye level

- be positive & honest -> don't lie abt pain

characteristics of approach to infants for physical assessments (5)

- use quiet, calm tone

- limit body heat loss

- assess between eating & sleeping cycles

- assess alertness

- observe movements for symmetry, coordination, & strength

where should you try to do infant & toddler physical assessments?

parents lap -> feel safer

infant sequence for physical assessment (5)

1. auscultate to heart, lungs, & abdomen

2. count resp by observation then vitals

3. palpate & percuss

4. start w chest then proceed head to toe

5. perform procedures on eyes, ears, & mouth last

characteristics to approach toddlers (12-36 months) for physical assessment (7)

- cautiously

- limit info -> short attention span

- keep hands busy

- praise cooperative behavior

- introduce equipment gradually

- inspect body areas through play

- no yes or no questions

how should you introduce equipment to toddlers?

allow them to touch but don't let them spend too much time on it

toddler sequence for physical assessment (3)

1. minimize physical activity initially

2. auscultate, percuss, then palpate whenever quiet

3. perform procedures on eyes, ears, & mouth last

characteristics of approach to preschooler (3-5) physical assessment (5)

- incorporate play -> demonstrate procedures

- likes to explore environment

- playful techniques

- simple, direct language

- give choices

preschooler sequence for physical assessment

if cooperative head to toe, but if not -> same as toddler

characteristics of approach to school age children (6-12) physical assessment (5)

- include written/visual info

- explain use of technique & reason for assessment

- elicit questions/concerns

- respect privacy

- usually prefers to sit

characteristics of approach to adolescents (11-18) physical assessment (3)

- privacy is very important

- concerned w body image -> reassure abt normal body changes

- usually not talkative in morning, but can get more social as day goes on

school age children & adolescent sequence for physical assessment

head to toe approach & should examine genitalia last

therapeutic play

effective technique in relating to child -> reduces trauma of illness & prepares child for procedures

typical order of assessment

1. inspection

2. palpation

3. percussion

4. auscultation

* auscultate abdomen before palpating or percussing

pediatric assessment of general appearance (7)

- alertness

- muscle tone

- resp effort

- presenting appearance

- body development & nutrition

- activity level

- cooperativeness

hx info to obtain during pediatric assessment (5)

- chief complaint & present illness

- birth hx

- immunizations

- growth & development

- functional hx -> diets, routines, habits

hx red flags in infants (4)

- feeding difficulties -> tired after feeding

- diaphoresis

- poor weight gain

- decreased wet diapers

cardiac dys red flags in older children (3)

- decreased exercise tolerance/activity level

- dyspnea on exertion

- fainting spells

pediatric assessment measurements (4)

- VS & pain assessment

- weight -> same scale & time of day if in pt

- height

- head circumference if

how should you measure height for peds assessment

- if

- use stadiometer standing upright for >4

what is a red flag when measuring head circumference?

circumference jumps more then 2 percentiles -> scan for brain bleed -> can signify abuse

how do you measure OFC?

from above eyebrows & ears to the largest part of the head in the back

circumference measurements taken on children

head, chest, & abdomen

how much weight should toddlers gain in 2.5 years or 30 months?

quadruple weight -> 4-6 lbs/yr

how much weight do preschoolers gain/yr?

5 lbs/yr

how much weight should children gain during their adolescence?

rapid growth patterns:

- females: 15-55 lbs

- males: 15-65 lbs

what do growth charts show?

a series of percentile curves -> height, weight, & head circumference

influencing factors on vitals (5)

- fever -> increase HR

- crying/anxiety/fear -> increase everything

- hypoxia/shock -> decrease CO

- movement

- meds

what should you compare peds vitals too?

age normal values AND pts -> recheck when calm if abnormal

VS order for infants & toddlers

1. assess comfort ;eve;

2. count resp

3. count apical HR

4. measure BP

5. measure temp

* 4 & 5 can be swapped depending

common temp site on neonate

axillary

common temp site on infant

rectal or axillary

- temporal if >3 months without fever risk

when can children take oral temps?

once its assured child understands & follows directions -> typically >5 y/o

what is classified at a fever for peds?

>100.4 F or 38 C

- if 38.5 -> get cultures

how do you properly take a temporal temp?

swipe along flush to forehead then touch back of the ear

- shouldn't beep until the very end

correct position of infant & child for rectal temp

- child -> side lying w legs flexed

- infant -> supine w legs bent toward chest

how far should you insert the probe for rectal temp?

- 1/2 in for infant

- 1 in for child

hypothermia

indication of inf -> newborns & infants at risk sp keep covered

what temp triggers sepsis alert?

36 C or less

what is the preferred location for listening to HR for peds?

apical when

where is the apex of the heart in an infant or young child?

4th intercostal space, medial to left mid clavicular line

where is the apex of the heart in an older adult?

5th intercostal space

how old should your pt be to take a radial pulse?

>2 y/o

how long should you listen to an infants HR for?

1 min -> can feel radial/brachial pulse to confirm rate

normal HR for newborn to 4 weeks

110-160

normal HR for infant (1-12 months)

90-160

normal HR for toddler (1-2 yrs)

80-140

normal HR for preschooler (3-5 yrs)

70-120

normal HR for school aged child (6-12 yrs)

60-110

normal HR for adolescent (12-18 yrs)

50-110

how do you do resp?

watch/palpate chest rise & fall -> preferred no stethoscope

- can watch abdominal movements if

what can tachypnea be an early indication for?

resp distress

apnea

20 secs w/o any breaths

normal resp for newborn to 4 weeks

30-60

normal resp for infant (1-12 months)

25-30

normal resp for toddler (1-2 yrs)

25-30

normal resp for preschooler (3-5 yrs)

20-25

normal resp for school aged children (6-12 yrs)

20-25

normal resp for adolescent (13-18 yrs)

16-20

how often should children get blood pressures?

annually for children 3 yrs & older -> earlier if at risk

BP site for infants & toddlers

calf -> higher rdg in calf

- should explain tight feeling to child is like a hug

expected BP of newborn - 4 weeks

65-74 / 40-50

expected BP of infant (1-12 months)

75-100 / 40-55

expected BP of toddler (1-2 yrs)

85-105 / 40-60

expected BP of preschooler (3-5 yrs)

90-110 / 50-70

expected BP of school aged (6-12 yrs)

95-120 / 55-80

expected BP of adolescent (13-18 yrs)

110-135 / 65-85

general sequence of head to toe assessment (5)

- skin

- head & neck -> eyes, ear, mouth, neuro

- chest -> lungs & heart

- abdominal

- musculoskeletal

general differences in children (6)

- head proportionally larger than body

- higher metabolic rate

- greater insensible losses

- poor temp reg

- immature immune sys

- immature organs

skin differences in children (5)

- thinner

- lower fat conc

- mottling is normal

- greater risk for skin breakdown

- seborrheic dermatitis -> cradle cap

types of visible skin discolorations in children (5)

- hyper pigmented nevi

- port wine stain -> nevus flammeus

- strawberry nevus -> hemangioma

- salmon nevie -> stork mark

- cafe au lait spots

hyper pigmented nevi

blue/gray irregular shaped macules:

- common in dark- skinned infants

- fade over time

- mistaken for bruise

cafe au lait spots

light brown macules, > 6 can indicate genetic condition

salmon nevi

light pink macule typically on eyelids, nasal bridge, back of neck -> usually fade overtime

strawberry nevus

raised reddish papule made of blood vessels -> present at or develop after birth

- usually gone by the age of 9 years

nevus flammeus

dark purple-red flat patch that grows with the child

- may be associated with Sturge-Weber syn

how can nevus flammeus be removed?

with laser therapy

phimosis

cannot retract foreskin of penis

paraphimosis

stuck in retraction -> emergency since can cut off blood flow

what should you look at in male genitalia exam? (4)

- foreskin

- undescended testes

- swelling in scrotum -> indicated inguinal hernia

- testicular enlargement -> first sign of puberty

what should you assess when looking at infants head? (3)

- symmetry & shape

- palpable ridge & balding spots

- fontanels

what should you assess when looking at necks? (3)

- typically short

- head control

- ROM

what should you assess when looking at eyes? (5)

- eyelid placement -> upper lid fall near upper iris

- iris round

- extra ocular movement -> asymmetric in newborns

- squinting -> check vision

- red reflex

what should you assess when looking at ears? (3)

- top of ears aligns w outer eye

- assess for pain & drainage

- leave for end of exam for younger children

how to eustachian tubes differ in children? (2)

-

- >3 y/o -> up & back

what should you assess when looking at nose? (2)

- drainage or secretions

- nasal flaring -> indicates resp distress

what should you assess when looking at mouth? (4)

- dental decay or presence of teeth

- palate -> intact, feel roof of mouth w finger

- oral candidiasis

- leave for end if younger

what should you assess when looking at neuro status? (5)

- LOC

- PERRLA

- orientation

- cough/gag reflex

- extremity strength

cranial nerves to assess in children (4)

- extra ocular movements

- facial movements

- shoulder shrug

- stick out tongue

what should you assess when looking at infant specific neuro status? (3)

- fontanels

- motor fxn -> posture, tone, muscle strength

- motility -> symmetry of movements

AVPU assessment for LOC

- A: awake & alert

- V: responds to voice

- P: responds to painful stimuli

- U: unresponsive

glasgow coma scale (3)

- eye opening (1-4)

- verbal response (1-5)

- motor response (1-6)

what should you assess when looking at chest? (3)

- size, shape, symmetry

- breast development/gynecomastia

- symmetric bilaterally w breathing -> >7 yrs thoracic resps

what should you assess when looking at resps? (5)

- rate

- rhythm

- depth

- quality

- symmetry

what should you not hear when auscultating lung sounds?

- crackles/rales -> fluid

- wheezes -> narrowed passages

- rhonchi -> secretions

- stridor -> obstruction